title: Effective antibiotic treatment prescribed by emergency physicians in patients admitted to the intensive care unit with severe sepsis or septic shock: where is the gap?
abstract: BACKGROUND
  Antibiotic selection made within the first hour of recognition of severe sepsis and septic shock has been shown to decrease mortality.
  
  
  OBJECTIVE
  The purpose of this study was to determine what antibiotics are being prescribed and to identify factors influencing ineffective antibiotic coverage in patients with severe sepsis or septic shock. In addition, we explore an alternative method for antibiotic selection that could improve organism coverage.
  
  
  METHODS
  This was a retrospective review of emergency department (ED) patients admitted to an intensive care unit (ICU) over a 12-month period with a culture-positive diagnosis of either severe sepsis or septic shock. Appropriate antibiotic therapy was defined as effective coverage of the offending organism based on final culture results.
  
  
  RESULTS
  Of the 1400 patients admitted to the ICU, 137 patients were culture positive and met the criteria for severe sepsis or septic shock. Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74-.88) of cases. Of the 25 patients who received ineffective antibiotics, the majority had infections caused by resistant Gram-negative organisms. Health care-associated pneumonia guidelines were applied to all patients, regardless of the source of infection, and were 100% sensitive (95% CI .93-1) for selecting patients who had infections caused by highly resistant organisms.
  
  
  CONCLUSIONS
  Emergency physicians achieved 82% effective antibiotic coverage in patients with severe sepsis or septic shock. The gap seems to be in coverage of highly resistant Gram-negative organisms. An alternative approach to antibiotic prescription, utilizing a set of guidelines for community- and health care-associated infections, was found to be 100% sensitive in selecting patients who had infections caused by the more resistant organisms.
authors.affiliation: Harvard Affiliated Emergency Medicine Residency Program, Brigham & Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Roberta
authors.initials: R
authors.lastname: Capp
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.forename: David F M
authors.initials: DF
authors.lastname: Brown
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D004635:Emergency Medicine; D004636:Emergency Service, Hospital; D005260:Female; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018805:Sepsis / Q000188:drug therapy* / Q000382:microbiology; D012772:Shock, Septic / Q000188:drug therapy / Q000382:microbiology
chemical_list: D000900:Anti-Bacterial Agents